Paul Markovich

Last month, The Washington State Insurance Commissioner's office imposed a substantial fine of $100,000 on Molina Healthcare of Washington due to significant enrollment and billing discrepancies. Their examination revealed that nearly 2,000 individuals received incorrect invoices, and 22 members were inappropriately terminated: https://shorturl.at/ektyY. This incident is a huge example of the broken American Healthcare System, particularly in managing provider data and processing claims accurately. Our solution, Provider Passport, addresses these challenges head-on with a Unified Provider Data Management Solution. Leveraging automation and AI, Provider Passport delivers real-time, precise provider data in minutes, resulting in faster Credentialing, PSV Packet creation, Payer Enrollment, Privileging, and Peer Reviews, among others. For more information, please visit: https://bit.ly/4arEH29 #HealthcareAdministration #Credentialing #PayerEnrollment #ClaimsProcessing

6

What does calling my cable company have to do with Medicaid? I had to call a certain notorious cable/internet provider recently. The one with customer service so bad that it was skewered in a classic South Park episode. I blocked out an hour and braced for my inevitable PCOM aneurysm rupture. Shockingly, it was a breeze. The rep was friendly, and my issue vanished in minutes—a far cry from their usual 'dial-one-to-scream-into-the-void' reputation. So, what changed? Competition happened. A decade ago, our choices for cable and internet were as limited as the soda options in a health spa. Now, thanks to a buffet of streaming services—even including live local TV—the old cable giants had to step up their game or step aside. Turns out, competition is more effective than caffeine at improving service quality. Why can't Medicaid beneficiaries get the same treatment? Currently, most Medicaid coverage is through Managed Care Organizations (MCOs), where the state pays a fixed monthly rate per patient. This model should spur cost-efficiency, but it often just limits the scope of care. Low payments to doctors, restricted access to necessary services—who does that help? Could strict government regulations guarantee better service? Maybe, but FA Hayek (and a basic reading of history) prove that bureaucracy alone can't engineer excellence. And choice for Medicaid patients? Virtually non-existent. Many areas offer just one MCO. If you're dissatisfied, too bad—there's no alternative. It's like being stuck with dial-up in the era of fiber optics. Long wait times for basic procedures, no freedom to seek better coverage... It's eerily reminiscent of the old cable monopoly days. In the private sector, at least there's a semblance of choice: HMOs, PPOs, HSAs... But for Medicaid recipients? Sorry, the state chooses for you. Hope you like it. Our Medicaid system desperately needs a dose of competition. Isn't it time we offer Medicaid patients the luxury of choice that drives quality up and costs down? https://t.co/C7XE6CpIIP Joe Grogan Lisa Grabert Joanne Spetz Cheerag Upadhyaya, MD, MBA, MSc, FAANS, FACS Brian R. Gantwerker, MD, FAANS, FACS Sanjay Dhall Larry Bucshon, M.D.

15

6 Comments

Recent legislative actions in California and Oregon signal progress towards state-level universal healthcare coverage, with proposed systems similar to Medicare for All. While proponents cite potential cost savings and improved access, opponents argue the actions could disrupt care and increase costs. https://bit.ly/49U7SKh Healthcare Dive #healthcare #HealthPlans #payments

11

The DxF is a groundbreaking statewide initiative led by CalHHS to build a unified data exchange system, ensuring seamless sharing of health and social services information across California. By connecting critical data, the DxF is set to improve patient care, enhance public health reporting, and promote health equity across the state. One key component is Compliance and Standards: San Diego Health Connect (SDHC) plays a vital role in ensuring that participants adhere to DxF data sharing requirements and standardized exchange methods. The framework emphasizes data governance, privacy, and security, which Qualified Health Information Organizations (QHIOs) must follow. Learn more: https://zurl.co/D3mV #CalHHS #DxF #HealthData #HealthEquity #PublicHealth #DataExchange #SHDC #HIE

6

Remember to tune in to Blue Shield of California's webinar on primary care delivery in California today at 12 PM PT. Learn from our CEO, Khanh Gia Nguyen, and other industry leaders on steps being taken to improve primary care service delivery in California and the launch of a value-based payment pilot. Register here: https://lnkd.in/eqwr4RH6 #primarycare #valuebasedcare #healthcareinnovation

14

Early bird pricing ends tonight! Get registered to attend California State Rural Health Association's annual conference before pricing goes up. Join us as we bring together healthcare leaders from rural clinics, hospitals, and rural health partners for a candid discussion about what rural health communities are doing to improve the quality and length of life of rural Californians. Register by using the link in the comment below! #CARuralHealth #HealthcareLeadership #StaffWellbeing #QualityCare

3

1 Comment

When hospitals are organized into multi-facility systems, it's very difficult to ensure that #Medicaid funds targeted by complex formulas to the safety net hospitals in the system that serve low-income patients and communities actually are used to improve care in those communities. Local groups in Fresno, CA are suing the local hospital system for disinvesting and diverting dollars away from the communities they are intended to serve. #Medicaid #hospitals https://lnkd.in/dNqFWwXV

1

Webinar Rescheduled! Calling All Health Information Exchanges (HIEs)... Don’t miss our webinar on November 14, 2024, from 12 PM - 1 PM: HIE Sustainability and EMS - How Your HIE Can Facilitate Exchange of Pre-Hospital Data. Join San Diego Health Connect as we delve into the essential role HIEs play in enabling the smooth transfer of pre-hospital data from EMS providers to hospitals. Discover how this data exchange boosts care coordination, enhances patient outcomes, and contributes to the sustainability of HIEs. Key Topics We’ll Cover: • Integrating EMS data into the healthcare system via HIEs • Real-time data sharing between EMS and emergency departments • Strengthening partnerships between EMS agencies, hospitals, and HIEs • Case studies of successful EMS data-sharing efforts • How SDHC’s hosted solution supports seamless integration of pre-hospital data Secure your spot today: https://zurl.co/SaXt #EMS #HIE #PreHospitalData #HealthcareIntegration #SDHC #CareCoordination

2

Great to reconnect with my old friend and former colleague, Patrick McDermott from Sutter Health, at the Becker’s Health IT + Digital Health + RCM Meeting! I thoroughly enjoyed his breakout session on denial management. His insights on root cause analysis and problem-solving, grounded in Lean Six Sigma principles, were refreshing and much needed in today’s healthcare landscape. Patrick emphasized how many organizations still struggle with understanding key metrics like 1st pass rates, which are often underutilized, and the need for variation analysis to solve for defects. He also pointed out that the absence of denial management committees and problem-solving groups is a missed opportunity for many. One of the most valuable takeaways was how basic training—like walking registration staff through the fields on a UB92—can make a significant difference in driving operational excellence. It’s such a simple, often overlooked step, but one with huge impact. Thanks, Patrick, for the great insights and practical takeaways! #BeckersConference #DenialManagement #RevenueCycle #LeanSixSigma #HealthcareLeadership #RCM

39

3 Comments

New #ManattOnHealth Insight by Lora Kim and Nina Punukollu: The Centers for Medicare & Medicaid Services (#CMS) just approved a historic #Medicaid expansion in Arizona, California, New Mexico and Oregon, marking the first time traditional #HealthCare practices will be covered under Medicaid and #CHIP. This landmark decision opens doors to culturally appropriate health care—aimed at tackling longstanding health disparities affecting American Indian and Alaska Native communities. Learn more: https://lnkd.in/ehsvJpMk

29

Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

6

Listen Here: https://lnkd.in/gH8YyX8b In this episode, George C. Halvorson, Chair and CEO of the Institute For InterGroup Understanding and former CEO of Kaiser Permanente, shares insights on the evolution of Medicare Advantage, its success in delivering quality care, and its role in shaping the future of healthcare. Halvorson delves into key topics like capitation, healthcare cost management, and the ongoing challenges facing the Medicare system. For more information about Becker's Healthcare, please contact Jessica Cole or Scott Becker. #podcast #healthcare #medicareadvantage

34

4 Comments

California has made remarkable strides in expanding health insurance coverage over the past 15 years. Here's what you need to know: 📊 The uninsured rate has plummeted from nearly 25% in 2009 to less than 10% today. 🤝 As of 2024, California is one of only two states offering state-funded health insurance to all low-income undocumented immigrants. 👥 While gaps remain, particularly for undocumented families above income thresholds, the state continues to push for broader coverage. 💰 Despite these achievements, healthcare costs in California remain higher than the national average, presenting ongoing challenges. 🔍 While universal coverage hasn't been achieved as initially envisioned, the state now focuses on universal access to care. Read more on our blog: https://lnkd.in/gzTe-qye What are your thoughts on California's progress? How can we further improve healthcare access and affordability? #HealthcareForAll #CaliforniaHealth #HealthEquity #AccessToCare

8

“When private equity firms get involved in health care, patients pay the highest price – in more ways than one.”    In a piece published in CalMatters, Edward Dudensing shares why California needs to prioritize senior care and oversight. Read his article here: https://lnkd.in/eaH_cQXW #SeniorCare #SeniorJustice 

3

How could Proposition 34 impact healthcare funding for low-income Californians? In our latest video, #USC Bedrosian Center senior fellow Mark Baldassare explores #Prop34, a measure that would require certain health providers to allocate 98% of profits from discounted drug sales to direct patient care. Though this initiative primarily targets the AIDS Healthcare Foundation, it would also allow California to negotiate #MediCal drug prices. Join us to discuss what a “yes” or “no” vote on Prop 34 could mean for healthcare funding, patient services, and California’s #healthcare landscape. Public Policy Institute of California

3

Medicare Advantage’s (MA) quality bonus program (QBP) pays plans based on a quality-based star rating system. However, issues with the QBP contribute to overpayments in MA and can exacerbate health disparities. We examine the QBP's design, issues around increases in star ratings, differences in access to high-quality plans, growth in QBP payments over time, and variations in QBP payments per enrollee. We also examine county- and state-level changes in QBP payments. QBP only provides bonuses and does not include any penalties for poor performance to balance the substantial rewards it provides to MA plans. Star ratings and QBP payments per enrollee increased from 2015 to 2023, substantially boosting payments to MA plans. In 2023, QBP payments totaled $12.9 billion. QBP payments disproportionately go to contracts with more advantaged beneficiaries. With geographic differences in access to higher-scoring plans, some beneficiaries do not have access to the additional benefits funded by QBPs. #Medicare

5

Private insurers involved in the government’s Medicare Advantage program made hundreds of thousands of questionable diagnoses that triggered extra taxpayer-funded payments from 2018 to 2021, including outright wrong ones like Lee’s, a WSJ analysis of billions of Medicare records found. The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea. Medicare Advantage, the $450-billion-a-year system in which private insurers oversee Medicare benefits, grew out of the idea that the private sector could provide healthcare more economically. It has swelled over the last two decades to cover more than half of the 67 million seniors and disabled people on Medicare. Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said. One reason is that insurers can add diagnoses to ones that patients’ own doctors submit. Medicare gave insurers that option so they could catch conditions that doctors neglected to record. The Journal’s analysis, however, found many diagnoses were added for which patients received no treatment, or that contradicted their doctors’ views. The insurers make new diagnoses after reviewing medical charts, sometimes using artificial intelligence, and sending nurses to visit patients in their homes. They pay doctors for access to patient records, and reward patients who agree to home visits with gift cards and other financial benefits. Insurers added diabetic cataract diagnoses to 148 patients treated by Dr. Howard Chen, an ophthalmologist in Goodyear, Ariz. He said he saw at most one or two such cases a year. He said he charges insurers $40 per patient to cover his costs for providing them with medical charts. He said he charges insurers $40 per patient to cover his costs for providing them with medical charts. “If they are just making stuff up, then why do they even need or want my charts?” said Chen. In all, Medicare paid insurers about $50 billion for diagnoses added just by insurers in the three years ending in 2021, the Journal’s analysis showed. The Journal reviewed the Medicare data under a research agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care. The Journal identified the patients named in this article through their doctors. Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

1

1 Comment

UC San Diego Health faced mounting financial pressures, including increasing inflation, poor payer rates and challenges with patient collections. FinThrive's Revenue Cycle Management Technology Adoption Model (RCMTAM) helped UC San Diego assess and enhance their Revenue Cycle Management technology without deviating from their existing strategic road map. This led to an increase of $2 million in point-of-service collections. Read more about the RCMTAM's results here: https://hubs.li/Q02S9glz0

11